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Health History Form

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To minimize your wait time at our office, we recommend that you download, print and fill out the Informed Consent Form, Health Care Authorization Form, and Financial Policy Form, and bring them with you to your next appointment.

For your convenience, and to minimize your wait time even further, you may fill out and submit the Health History Form online.

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For your convenience, and to minimize your wait time even further, you may fill out and submit the Health History Form online.

Please fill in the following form and submit it to electronically.
You may also fill out the form, print it, and bring it with you to your next appointment.

Patient Information

Last Name

First Name

Middle

Patient Address

Zip Code

Male

Female

Phone No

Date of Birth

SSN

Parent/Legal Guardian

Name

Address

Zip Code


Daytime Phone	Other Phone

Dental Insurance

Dental Insurance Name

Group No

Insurance Company Address

Zip Code


Name of Insured	Date of Birth	SSN

Address of Insured

Zip Code

Employer's Name

Emergency Contact

Name	Phone

Patient Health History

Is the patient in good health?

Is the patient currently under the care of a physician?

Have there been any changes in general health within the past year?

Have there been alergies or reactions to any medication or drugs?

Has there ever been any excessive bleeding requiring treatment?

Has the patient ever required a blood transfusion?

Has the patient ever had the following:

Y	N		Y	N		Y	N
		Heart Failure			Asthma			Tuberculosis
		Heart Disease			Anemia			Hepatitis A or B
		Heart Surgery			Diabetes			AIDS or HIV
		Heart Murmer			Lukemia			Hemophilia
		Angina Pectoris			Allergies			Epilepsy / Seizures
		Rheumatic Fever			Artificial Joint			Venereal Disease
		Artificial Heart Valve			Kidney Trouble			Genital Herpes
		High Blood Pressure			Thyroid Disease			Cold Sores
		Breathing Problems			Liver Disease			Cancer
		Others not listed
		Medications Taken

Dental

Medical

Date of last
Dental Exam:

Date of last
Medical Exam:

Dentist's Name:

Physician's Name:

Phone Number:

Office Address:

City and Zip:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in medical status.


Date	Signature of Parent or Guardian	How were you referred to our office?

Health History Form

Patient Center

On Your First Visit

Kids with Special Needs

After Care

Financing Available

Health History Form

PDF Health Forms